Acute Coronary Syndrome Flashcards

Question

Does ST-elevation MI have elevated cardiac enzymes? ST-segment elevation?

Answer 1

Elevated cardiac enzymes- Yes | ST-segment elevation- Yes

Answer 2

Those with ST- elevation

Answer 3

High risk--TIMI score 5-7 points Medium risk--TIMI score 3-4 points Low risk --TIMI score 0-2 points

Answer 4

- Lower heart rate - Lower systolic blood pressure - Ease cardiac contractility - Reduce left ventricle dimension (preload)

Answer 5

- Dilate coronary arteries - Enhance coronary blood flow; reduce clot size - Reduce left ventricular end-diastolic pressure - Prolong diastole (increased coronary perfusion)

Answer 6

- Decrease mortality - Establish balance between oxygen supply and demand (reverse ischemia) to relieve symptoms - Reverse ischemia to prevent necrosis or limit infarct size and decrease complications

Answer 7

- Oxygen- every patient should be placed on this due to once of our goals being increase ox. - Stool softeners- important so that patients arent straining while having an MI this will make it worse - Bedrest - Diet- no sodium - Anxiolytics- really anxious so help with the anxiety

Answer 8

Percutaneous coronary intervention PCI is a stent that is placed (usually drug eluting, will help to stop the progression of the plaque and buildup and remodeling) this breaks up the clot and allows for good blood flow to the tissue.

Answer 9

Percutaneous Transluminal Coronary Angioplasty (PTCA) with coronary stent placement --1-2 vessel disease or proximal stenosis Initial success rate 80-90% for opening vessels --Drug-eluting stents have been shown to reduce restenosis rates --Contain drugs which inhibit smooth muscle cell proliferation and inflammatory cell activity

Answer 10

If primary PCI is feasible and can be performed quickly it is generally preferred over fibrinolytic therapy for treating acute STEMI

Answer 11

Direct coronary atherectomy | The excision of atherosclerotic plaque using rotating blades

Answer 12

Improves survival in high risk patients

Answer 13

- -Significant stenosis of left main coronary artery - -Proximal LAD stenosis and proximal left circumflex stenosis > 70% - -Triple vessel disease - -Impaired left ventricular function

Answer 14

- Nitrates- Nitroglycerin - Analgesics - Fibrinolytics (Thrombolytics) - Antiplatelet drugs - Anticoagulants - Beta Blockers - ACE Inhibitors - Calcium Channel Blockers

Answer 15

- direct vasodilators of veins (low dose) and arteries (high dose) - venodilation = ↓ preload = ↓ wall tension and -ventricular dimensions - dilate epicardial vessels and ↑ blood flow to collateral vessels - alleviate coronary spasm

Answer 16

Ischemic heart disease Heart failure Hypertensive emergencies

Answer 17

- anti-anginal - increases coronary blood flow to the heart - reduces cardiac workload

Answer 18

- reduces cardiac workload by reducing preload | - typically used in conjunction with an afterload--reducing agent (esp.hydralazine)

Answer 19

- vasodilator; quickly reduces blood pressure | - only the intravenous form is used for blood pressure reduction

Answer 20

- True mechanism unknown; some hypotheses: - Sulfhydryl group depletion - Activation of the sympathetic nervous system - Na and H2O retention = plasma volume expansion - Deactivation of nitric oxide by superoxide free radicals

Answer 21

- 10-14 hour nitrate-free interval | - Use nitrates cautiously as monotherapy since angina may occur during the nitrate-free period

Answer 22

- Headache (frequently dose-limiting) - Syncope and hypotension (potentiated by alcohol, hot weather, or hot bath) - Dizziness - Tachycardia (rebound)

Answer 23

- Keep nitrates stored in airtight containers in a dark, cool, dry place - Caution when standing, may precipitate lightheadedness - Seek immediate medical attention if pain not relieved within 5 minutes by one SL tablet - Dry mouth may slow disintegration of SL tablets - Remove patch for 10-12 hours each day to provide a nitrate-free interval and use a new patch each day - Replace SL NTG vials every 6 months

Answer 24

- Severe bradycardia ( < 50 bpm) - Tachycardia (> 100 bpm) - SBP < 90 mmHg or > 30 mmHg below baseline - Should not be administered to patients who have received a phophodiesterase inhibitor! - -Within 24h of Sildenafil - -Within 48 h of Tadalafil

Answer 25

- Recurrent angina or Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy - Elevated cardiac biomarkers (TnT or TnI) - New or presumably new ST-segment depression - Signs or symptoms of HF or new or worsening mitral regurgitation - High-risk findings from noninvasive testing - Hemodynamic instability - Sustained ventricular tachycardia - PCI within 6 months - Prior CABG - High risk score - Reduced left ventricular function (LVEF less than 40%)

Answer 26

- Low risk score | - Patient or physician preference in the absence of high-risk features

Answer 27

Benefit >>> Risk Treatment SHOULD be administered Recommendation that treatment is useful/effective

Answer 28

Benefit >> Risk IT IS REASONABLE to administer treatment Recommendation in favor of treatment being useful/effective

Answer 29

Benefit > Risk Treatment MAY BE CONSIDERED Recommendation’s usefulness/efficacy less well established

Answer 30

Risk > Benefit Treatment should NOT be administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL Recommendation that treatment is not useful/effective and may be harmful

Answer 31

Take 1 SL NTG in response to chest pain/discomfort (if unimproved or worsened after 5 min call 911 (Class I) Patients with ongoing ischemic discomfort should receive SL NTG q 5 min for a total of 3 doses (Class I) After 3 doses assess for need for IV NTG (Class I) IV indicated in first 48 hours for treatment of persistent ischemia, HF, or hypertension

Answer 32

Continued use of NTG beyond 1st 48 hours in absence of continued or recurrent angina or HF may be helpful although benefit likely small and not well established (Class IIb)

Answer 33

Sedative properties tend to decrease anxiety Causes venodilation Vagal activity decreases HR and BP

Answer 34

Administer if there is uncontrolled ischemic chest discomfort despite NTG (Class IIa)

Answer 35

Analgesic of choice for management of pain (Class I)

Answer 36

``` STREPTOKINASE Anistreplase ALTEPLASE Retelplase Tenecteplase ```

Answer 37

- Fibrinolytic therapy should be admin with symptom onset within the prior 12 hours and ST elevation greater than 1mm in at least 2 continguous precordial leads or at least 2 adjacent limb leads (Class I) - Or sx onset within prior 12 hours and presumably new left branch bundle block (Class I) - Sx onset within prior 12 hours and 12-lead ECG findings consistent with true posterior MI (Class IIa) - Sx onset within prior 12-24 hours who have continuing ischemic sx and ST elevation > 1mm in at least 2 continguous precordial leads or 2 adjacent limb leads (Class Iia- no good studies that show pas12 hours that there is benefit) - Fibrinolytic therapy should not be administered to patients whose initial symptoms began more than 24 hours earlier (Class III)

Answer 38

- ASA (162-325mg) should be chewed by patients who have not taken ASA before presentation - Clopidogrel (plavex) should be admin to patients unable to take ASA

Answer 39

- Clopidogrel (plavex)should be added to ASA and an anticoagulant ASAP after admission and continued for at least 1 month ideally up to 1 year (doesn’t mean upon adminsion) - If recurrent sx of ischemia, HF, or serious arrhythmias subsequently appear then diagnostic angiography should be performed. Prior to performing angiography either an IV GPIIb/IIIa inh or clopidogrel should be added to ASA and an anticoagulant.

Answer 40

- Either clopidogrel (plavex) or an IV GP IIaIIIb inh should be added to ASA prior to diagnostic angiography - Abciximab (is the only IIaIIIB inhibitor apprioved is PCI is going down) is indicated here only if no appreciative delay in angiography and PCI is likely to be performed - Otherwise IV eptifibatide or tirofiban is preferred

Answer 41

--(Class IIa) Conservative For patients with recurrent ischemic discomfort with clopidogrel, ASA, and anticoagulant therapy it is reasonable to add a GPIIaIIIb inh before diagnostic angiography Invasive Reasonable to admin antiplatelet with both clopidogrel and IV GPIIaIIIb inh. Abciximab only if no delay in angiography and PCI to be performed, otherwise eptifibatide or tirofiban are preferred --(Class IIb) For patients in whom an initial conservative strategy is selected it may be reasonable to add IV eptifibatide or tirofiban to anticoagulant and oral antiplatelet therapy --(Class III) Abciximab should not be admin to patients in whom PCI is not planed

Answer 42

--ASA (162-325mg) should be chewed by patients who have not taken ASA before presentation Clopidogrel should be admin to patients unable to take ASA --Clopidogrel 75 mg should be added to ASA regardless of whether they undergo reperfusion with fibronolytic therapy or not. Treatment should continue for at least 14 days

Answer 43

- In patients < 75 years who receive fibrinolytic therapy or who do not receive reprofusion therapy it is reasonable to administer oral loading dose of clopidogrel 300mg - It is reasonable to start treatment with abciximab as early as possible before PCI

Answer 44

- Abciximab and half dose reteplase or tenecteplase may be considered for STEMI in selected patients: anterior MI, < 75 years; and not risk factors for bleeding - Treatment with tirofiban or eptifibatide may be considered before primary PCI

Answer 45

- Abciximab and half dose reteplacse or tenecteplase should not be given to patients aged > 75 years because of an increased risk of ICH - Full dose fibrinolytic therapy followed by immediate PCI may be harmful

Answer 46

Act to prevent thrombus formation

Answer 47

Anticoagulant therapy should be added ASAP Conservative: Regimens with either enoxaparin or UFH have strongest data support followed by fondaparinux In patients who have an increased risk of bleeding fondaparinux is preferable Invasive: Enoxaparin and UFH have strongest support followed by bivalirudin and fondaparinux

Answer 48

- If initial conservative strategy enoxaparin or fondaparinux is preferable to UFH unless CABG is planned within 24 hours - If initial invasive strategy reasonable to omit IV GPIIaIIIb inh prior to diagnostic angiography if bivalirudin is selected as anticoagulant and at least 300 mg clopidogrel admin at least 6h earlier than planned catheterization or PCI

Answer 49

- Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of hospitalization, up to 8 days. Anticoagulant regimens with established efficacy include: - -UFH (up to 48 hrs)- heparin - -Enoxaparin (in the absence of renal dysfunction; continued for the duration of hospitalization, up to 8d) - -Fondaparinux (in the absence of renal dysfunction; continued for the duration of hospitalization, up to 8d)

Answer 50

- For prior treatment with UFH, administer additional boluses as needed for the procedure. Bivalirudin may also be used. - For prior treatment with enoxaparin, if the last Sub Q dose was administered within the prior 8 hours, give no additional doses; if the last Sub Q dose was administered at least 8-12 hours earlier, give an IV dose of 0.3 mg/kg. - For prior treatment with fondaparinux, give additional IV treatment with an anticoagulant possessing anti-IIa activity.

Answer 51

It is reasonable for patients with STEMI who do not undergo reperfusion therapy to be treated with anticoagulant therapy (non-UFH regimen) for the duration of theindex hospitalization, up to 8 days.

Answer 52

- Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. - LMWH should not be used as an alternative to UFH as ancillary therapy in patients > 75 years of age who are receiving fibrinolytic therapy. - LMWH should not be used as an alternative to -UFH as ancillary therapy in patients < 75 years of age who are receiving fibrinolytic therapy but have significant renal dysfunction (serum creatinine > 2.5 mg/dL in men or 2.0mg/dL in women).

Answer 53

- -Limit myocardial damage and mortality when used for acute STEMI - -Reduce reinfarction and mortality when used chronically post-STEMI - -Begin with IV as indicated acutely, then switch to PO that same day. May start with oral in moderate to low risk patients

Answer 54

- HR< 50bpm, Heart block, Hypotension (SBP< 100 mmHg), Mod-severe LV dysfunction, COPD, asthma, signs of peripheral hypoperfusion - If contraindications exist in acute MI setting, BB can and should be started late (If contraindications resolve) with PO therapy

Answer 55

ORAL BETA-BLOCKERS therapy should be initiated within the first 24 h for patients who do not have signs of heart failure or evidence of a low-output state or other relative contraindications to beta blockade (heart block, active asthma, or reactive airway disease)

Answer 56

It is reasonable to administer IV BETA BLOCKERS at the time of presentation for hypertensive patients who do NOT have signs of HF or evidence of a low-output state or other relative contraindications to beta blockade

Answer 57

IV BETA BLOCKERS should NOT be administered to patients who have signs of HF or low-output state, risk factors for cardiogenic shock, or other relative indications to beta-blockade

Answer 58

- Decrease progression to CHF, reinfarction, and mortality | - Limit post-infarction left ventricular dilatation and hypertrophy (remodeling) and preserve ventricular pump function

Answer 59

- Patients with left ventricular ejection fractions < 40% may derive the most benefit - Therapy should begin ASAP - KEEP IN MIND: these patients will also be on a beta-blocker; therefore start the ACE inhibitor only when the patient is hemodynamically stable

Answer 60

An ACE INHIBITOR should be administered ORALLY within the first 24 h to patients with anterior infarction, pulmonary congestion or LV ejection fraction (LVEF) < 40%, in the absence of hypotension (SBP < 100 mm Hg or < 30 mmHg below baseline) - An ANGIOTENSIN RECEPTOR BLOCKER should be administered to UA/NSTEMI patients who are intolerant of ACE inhibitors - An ANGIOTENSIN RECEPTOR BLOCKER should be administered to STEMI patients who are intolerant of ACE inhibitors and who have either clinical or radiological signs of heart failure or LVEF < 40%. VALSARTAN AND CANDESARTAN have established efficacy for this

Answer 61

An ACE INHIBITOR administered ORALLY within the first 24 h can be useful in patients without anterior infarction, pulmonary congestion or LVEF < 40% in the absence of hypotension. The expected treatment benefit in such patients is less (5 lives saved per 1000 patients treated) than for patients with LV dysfunction

Answer 62

An INTRAVENOUS ACE INHIBITOR should NOT be given to patients within the first 24 hrs because of the increased risk of hypotension. (A possible exception may be patients with refractory HTN)

Answer 63

- No beneficial effect on death or nonfatal MI | - May increase mortality in some patient groups (LV dysfunction, Pulmonary Edema)

Answer 64

In patients with continuing or frequently recurring ischemia and in whom BB are contraindicated Verapamil or Diltiazem should be given as initial therapy in absence of significant left ventricular dysfunction or other contraindications

Answer 65

Long-acting Verapamil or Diltiazem are reasonable to use for recurrent ischemia in absence of contraindications after BB and nitrates have been fully used

Answer 66

Use of ER Verapamil or diltiazem instead of a BB may be considered IR dihydropyridine CCB in presence of adequate beta blockade may be considered in patients with ongoing ischemic sx or HTN

Answer 67

IR dihydropyridine CCB should not be admin to patients with NSTEMI/UA in the absence of a beta blocker

Answer 68

It is reasonanle to give Verapamil or Diltiazem to patients in whom BB are ineffective or contraindicated for relief of ongoing ischemia or control of rapid ventricular response with afib after STEMI in absence of CHF, LV dysfunction, or AV block

Answer 69

- Verapamil and diltiazem contraindicated in patients with STEMI and associated systolic LV dysfunction and CHF - Nifedipine IR form is contraindicated because of reflex sympathetic activation, tachycardia, and hypotension associated with its use

Answer 70

``` Give ASAP* ASA- CHEW IT NTG- sublinguial every 5 mins x 3 doses Beta-Blocker Ace Inhibitor ```

Answer 71

ASA (use indefinitely)+ Clopidogrel length of Clopidogrel as follows: NSTEMI/UA No stent/bare metal stent: at least 1 month up to12 months Drug eluting stent: at least 12 months) STEMI Bare metal and drug eluting as above Thrombolytic at least for 14 days

Answer 72

All patients should be given SL NTG | Long acting oral nitrates may be used to prevent ischemic symptoms

Answer 73

(Class I) Are indicated for all patients recovering from ACS unless contraindicated (for those at low risk, see Class IIa recommendation below). Treatment should begin within a few days of the event, if not initiated acutely, and should be continued indefinitely. Patients recovering from ACS with moderate or severe LV failure should receive BETA BLOCKER therapy with a gradual titration scheme.

Answer 74

(Class IIa) It is reasonable to prescribe BETA BLOCKERS to low-risk patients (i.e., normal LV function, revascularized, no high-risk features) recovering from ACS in the absence of absolute contraindications.

Answer 75

- Should be given and continued indefinitely in all patients recovering from ACS with HF, LV dysfunction (ejection fraction less than or equal to 40%), hypertension, diabetes mellitus, or chronic kidney disease, unless contraindicated. - An ARB should be prescribed at discharge to patients who are intolerant of an ACE inhibitor and who have either clinical or radiological signs of HF and LVEF < 40% It is beneficial to use an ARB in other patients who are ACE inhibitor intolerant and have hypertension. - Long-term ALDOSTERONE RECEPTOR BLOCKAGE should be prescribed for post-MI patients without significant renal dysfunction (estimated creatinine clearance should be > 30 mL/min) or hyperkalemia (potassium should be < 5 mEq/L) who are already receiving therapeutic doses of an ACE inhibitor, have an LVEF < 40%, and have either symptomatic HF or diabetes mellitus.

Answer 76

ACE INHIBITORS are reasonable for patients recovering from ACS in the absence of LV dysfunction, hypertension, or diabetes mellitus unless contraindicated. In patients who do not tolerate ACE inhibitors, an ARB can be a useful alternative in long-term management provided there are either clinical or radiological signs of HF and LVEF less than 40%

Answer 77

The combination of an ACE INHIBITOR and an ARB may be considered in the long-term management of patients recovering from ACS with persistent symptomatic HF and LVEF < 40% despite conventional therapy including an ACE inhibitor or ARB alone.

Answer 78

-Decrease cardiovascular mortality and all-cause mortality in patients with a variety of cholesterol concentrations -Hypercholesterolemic patients benefit most, but patients with normal cholesterol levels also benefit Good for both primary (prevents first event) and secondary (prevents recurrence of an event) prevention of myocardial infarction

Answer 79

(Class I) Statins, in the absence of contraindications, regardless of baseline LDL-C and diet modification, should be given to post-ACS patients For patients with LDL-C > 100 mg/dL, cholesterol-lowering therapy should be initiated or intensified to achieve an LDL-C of < 100 mg/dL. (Class IIa) Further reduction of LDL-C to < 70 mg/dL is reasonable. (Class IIb) Encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per d) for risk reduction may be reasonable. For treatment of elevated triglycerides, higher doses (2 to 4 g per d) may be used for risk reduction.

Answer 80

- Calcium channel blockers are recommended for ischemic symptoms when beta blockers are not successful, contraindicated, or cause unacceptable side effects. - Verapamil and diltiazem are preferred in the absence of severe left ventricular dysfunction or other contraindication.

Answer 81

(Class III) Short-acting dihydropyridine calcium channel antagonists should be avoided.

Answer 82

Managing warfarin to an INR (internationalized ratio for how fast the blood clots, normally want to be between 2-3 seconds) equal to 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-MI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus)

Answer 83

In patients requiring WARFARIN, CLOPIDOGREL AND ASPIRIN therapy, an INR of 2.0 to 2.5 is recommended with low dose aspirin (75 mg to 81 mg) and a 75 mg dose of clopidogrel.

Answer 84

Use of warfarin in conjunction with ASA and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely